The attitude towards narcotic and dangerous drug addiction may vary from one of nonchalance, of horror, of defeatism, or of reasonably restrained optimism, all of which may be more or less justified if one uses isolated individual problems in certain areas to justify conclusions.

The problem, while a world-wide one, must be viewed in the light of the individual areas, the cultural susceptibility and the philosophical attitudes of the population of the nations involved. The English and the Scots may, as a nation, drink too much scotch, but as a nation of restrained individuals have no serious narcotic problems; just as they have only minor problems in the fields of divorce or alcoholism.

The Crown Colony of Hong Kong, governed by the same laws as England, presents an astronomic problem in the number of its heroin addicts, so conclusions cannot be drawn on the basis of the laws in England.

Narcotic addiction does not appear to be a problem in Mexico, and yet narcotics illegally obtained from Mexico present a real problem in California and in adjacent cities in Texas.

So-called minority groups are negligible in England and are substantial in the United States; and these groups - namely, Negroes, Mexicans, and Puerto Ricans - probably represent 70% of the addicted population, whereas they represent approximately 16% of the population of the United States. On the other hand, the general approach of containment in the United States seems reasonably successful, since when narcotics were available restriction, some fifty years ago, it is estimated that one in four hundred of the population was addicted, whereas at the present time the figure is about one in three thousand.

Interestingly enough, the addiction rate in physicians in the United States, with their easy accessibility to narcotics, is about one in four hundred. We may possibly assume from this that the unstable individual to whom the addiction to narcotics is one evidence of instability represents about one in four hundred of the population. It would therefore seem somewhat more practical to make narcotics unavailable to this individual than to bother with the psychiatric approach of changing his personality so that narcotics will seem undesirable to him.

This attitude may represent that of a surgeon confronted with an ulcer patient who feels that while his reasons for developing an ulcer are psychological, it might be simpler to try to change his gastric secretions rather than change his personality, and therefore the surgeon recommends vagotomy and partial gastrectomy. In a humorous vein, this may be somewhat in line with the approach of the W.C.T.U. who maintained that if there was no alcohol available there would be no alcoholics. The only difficulty in accepting this point of view is that it receives no enthusiasm from those who feel they can handle alcohol in moderation.

Many well-meaning people are preoccupied with the idea that if the addicted individual could be furnished narcotics at cost, the profit motive would therefore be eliminated and the peddler driven out of business. They, unfortunately, do not seem to realize the astronomical tolerance which an addict, in general, develops, so that while he would accept all the cheap narcotics available, he would still go to the peddler for his overage.

This approach was tried in the early twenties in some large cities in the United States and was a dismal failure, as crime did indeed increase and addiction also increased.

One must start off with the assumption that narcotic addiction is either desirable or undesirable, and if it is indeed undesirable then the approach should be to eliminate it rather than perpetuate it.

The addicted person should be regarded as a sick person, but should be quarantined in a narcotic-free environment to determine whether or not he can be given motivation to eliminate his addiction, or, if addiction is merely an incident in a life of nonconformity, then it must be assumed that he is expendable and should be kept out of circulation.

As law enforcement agencies will well state, they do not argue the merits of either approach but the more addicts there are out of circulation, the less crime there is in the community.

Much misinformation exists as to the myth of the problems of the addict. Withdrawal symptoms, while severe, only last three or four days, as evidenced by many conservations with physician addicts. Physician addicts in California have shown a 92% rehabilitation rate largely because motivation can be created. In a large series, with a ten-year follow-up, the 92% figure appears to be constant and is brought about in the following way; the doctor's licence to practise medicine is revoked, and this is a very severe penalty to the average doctor, to whom medecine is a way of life more than a way of earning a living.

The revocation, however, is suspended on certain probationary terms - namely, that for a period of five years he will not have narcotics in his possession or prescribe them to his patients. This, at first, may seem rather harsh; but such patients as need narcotics are usually hospital patients, and these narcotics can be furnished by a resident, a colleague, or an anaesthesio-logist. The doctor is informed, however, that if narcotics are found in his possession at any time, the revocation of suspension is lifted and he loses his licence outright. This is a fine combination of fear of punishment and hope of reward.

Another important facet of rehabilitation of the addicted physician is that he reports every three or four months to a sponsor who encourages him to continue his practice under these terms, pointing out that 92% of his colleagues have made the grade and that the 8% who returned to addiction invariably committed suicide; a rather narrow choice. The sponsor usually contacts the hospital staff of the one-time addicted physician and points out that he should be encouraged to feel he is a member of the team again, and should be given hospital privileges even if under supervision. As a once addicted physician stated, "Doctor, you just don't understand what it's like to be on the wrong side of the law." In theer words, the doctor wants to have a certain sense of pride in being back on the team, rather than being looked down upon by his associates.

It is generally assumed that if one has been addicted for a long time, there is no hope of rehabilitation. This just is not true, as evidenced by numerous instances and particularly one which came to my attention as a long-time member of the California State Board of Medical Examiners. This man had been addicted for eighteen years and had travelled widely and purchased narcotics over the counter in many countries. He was tremendously overweight and had chronic phlebitis with severe leg pains. When his physician refused to prescribe narcotics for him, he forged prescriptions for himself and was apprehended. His attitude was quite hostile, stating that if he were furnished with narcotics, he could carry on a reasonable practice of internal medicine and felt that narcotics were justified in view of his severe leg pains.

It was pointed out that we did not feel that narcotics every four hours around the clock constituted legitimate treatment for phlebitis, so his licence to practise medicine was revoked outright. He left the hearing quite hostile and disturbed by the Board's apparently unsympathetic attitude. He returned a year later, a changed man. He stated that we had done him a tremendous favour in revoking his licence to practise and that he realized now that he was using his so-called phlebitis and leg pains as a crutch to justify his addiction, and that since he had been without narcotics, he had been able to tolerate his leg pains with aspirin. Interestingly enough, he stated that he did not want to have his narcotic licence restored - because he felt he was a weak character and if the going got a little rough, he might return to addiction - but merely wanted to be allowed to practise medicine without any narcotics privileges whatsoever. Time has apparently proved the wisdom of his own appraisal of his condition, as some ten years later he is practising internal medicine without access to narcotics.

The narcotics problem and the dangerous drug problem are comparable in that they could each be eliminated with honesty and integrity involving the source of supply. The tremendous over-production of coca leaves and the very great over-production of opium supplemented by much larger illegal crops for illicit purposes and the excessive manufacture of such dangerous drugs as barbiturates are an indictment of quite a number of countries in all parts of the world. It is estimated that the legitimate world need for opium represents about one thousand tons a year, whereas, world production is estimated at twelve to fifteen thousand tons per year.

One cannot pass laws to ensure morality, but if a great excess of narcotics and dangerous drugs beyond legitimate needs is produced, then the temptation to abuse is apparently insurmountable. Some countries state that they would not have any illicit production of narcotic drugs, heroin for instance, if it were not for the demand of neighbouring countries.

Narcotic addiction in physicians; medical and legal aspects of rehabilitation 13 drugs may also help in sup Introduction of passport control for tourists over a border over which there is an illicit flow of narcotic pressing this traffic, since the government of the country in which the illicit drugs originate would be put under pressure to suppress that trade if it were threatened by measures liable to reduce the number of tourists. On the other hand, in a receiving country it is a fact that certain pharmaceutical houses, in accepting orders from drug stores over the border for astronomical amounts of amphetamines and barbiturates beyond their legitimate needs, can hardly be justified on a moral basis if they are aware of the fact that these are destined for over-the-counter sale without medical indications.

Thus supposing there is an approach, however halfhearted, by one government to bring pressure on another government to clean its house, such an approach will be without effect if the former government is unwilling to clean house in its own legal industry and continues to export dangerous drugs beyond the legitimate needs of the countries to which these drugs are exported.

There is a tremendous interest on the part of the public in the United States in the narcotics problem as evidenced by a White House Conference on Narcotics, dealing with the problem on a national scale, as well as many regional conferences. In attending these conferences, one is impressed by the fact that the public does not feel that fifty thousand addicts in the United States with a population of one hundred and eighty-five million represents an irreducible minimum of unstable individuals. There is a strong demand for action and for a programme which will materially reduce this number, particularly since recent Supreme Court decisions, strictly interpreting search and seizure laws, have apparently operated in a manner to increase crime and protect the narcotics peddler.

The impression is gained that the public itself wishes protection and that legislation changing the rules is inevitable. Just as treason and sabotage in war time appears to justify separate rules, so the seriousness of addiction danger to the individual and the community would appear to justify legislation liberalizing searches and seizures; introduction of evidence and protection of informers. It would appear logical that special situations justify special rules. Another legal facet of the situation is the acceptance of the doctrine of civil commitment of the addict in order to bring about his rehabilitation in a narcotics-free environment. Mechanisms of voluntary commitment should also be strengthened in the interest of rehabilitation of the addict.

Experiences in Hong Kong have shown that the highest rehabilitation rate is in those addicts who are taught trades and can return to a useful occupation. The high rehabilitation rate in physicians, who can return to their practice, further buttresses this approach.

During the past fifteen years, lectures by knowledgeable physicians, psychiatrists, and law enforcement officers have been given to medical students in the Los Angeles area. The very low incidence of addiction in physicians exposed to these lectures would indicate that this should be a part of the curriculum in all medical shcools.

The narcotic addict can be rehabilitated if motivation is present or can be created. The more effective control of the source of narcotics and dangerous drugs can also achieve this end result. Experience in rehabilitation of physician addicts justifies restrained optimism.